Feasibility study of multimodal imaging for redox status and glucose metabolism in tumor

Understanding the tumor redox status is important for efficient cancer treatment. Here, we noninvasively detected changes in the redox environment of tumors before and after cancer treatment in the same individuals using a novel compact and portable electron paramagnetic resonance imaging (EPRI) device and compared the results with glycolytic information obtained through autoradiography using 2-deoxy-2-[18F]fluoro-d-glucose ([18F]FDG). Human colon cancer HCT116 xenografts were used in the mice. We used 3-carbamoyl-PROXYL (3CP) as a paramagnetic and redox status probe for the EPRI of tumors. The first EPRI was followed by the intraperitoneal administration of buthionine sulfoximine (BSO), an inhibitor of glutathione synthesis, or X-ray irradiation of the tumor. A second EPRI was performed on the following day. Autoradiography was performed after the second EPRI. After imaging, the tumor sections were evaluated by histological analysis and the amount of reducing substances in the tumor was measured. BSO treatment and X-ray irradiation significantly decreased the rate of 3CP reduction in tumors. Redox maps of tumors obtained from EPRI can be compared with tissue sections of approximately the same cross section. BSO treatment reduced glutathione levels in tumors, whereas X-ray irradiation did not alter the levels of any of the reducing substances. Comparison of the redox map with the autoradiography of [18F]FDG revealed that regions with high reducing power in the tumor were active in glucose metabolism; however, this correlation disappeared after X-ray irradiation. These results suggest that the novel compact and portable EPRI device is suitable for multimodal imaging, which can be used to study tumor redox status and therapeutic efficacy in cancer, and for combined analysis with other imaging modalities.

Surface dielectric resonator for in vivo EPR measurements

This research report describes a novel surface dielectric resonator (SDR) with a flexible connector for in vivo electron paramagnetic resonance (EPR) spectroscopy. Contrary to the conventional cavity or surface loop-gap resonators, the newly developed SDR is constructed from a ceramic dielectric material, and it is tuned to operate at the L-band frequency band (1.15 GHz) in continuous-wave mode. The SDR is designed to be critically coupled and capable of working with both very lossy samples, such as biological tissues, and non-lossy materials. The SDR was characterized using electromagnetic field simulations, assessed for sensitivity with a B1 field-perturbation method, and validated with tissue phantoms using EPR measurements. The results showed remarkably higher sensitivity in lossy tissue phantoms than the previously reported multisegment surface-loop resonators. The new SDR can provide potential new insights for advancements in the application of in vivo EPR spectroscopy for biological measurements, including clinical oximetry.

OxyChip embedded with radio-opaque gold nanoparticles for anatomic registration and oximetry in tissues

PURPOSE

Electron paramagnetic resonance oximetry using the OxyChip as an implantable oxygen sensor can directly and repeatedly measure tissue oxygen levels. A phase I, first-in-human clinical study has established the safety and feasibility of using OxyChip for reliable and repeated measurements of oxygen levels in a variety of tumors and treatment regimens. A limitation in these studies is the inability to easily locate and identify the implanted probes in the tissue, particularly in the long term, thus limiting spatial/anatomical registration of the implant for proper interpretation of the oxygen data. In this study, we have developed and evaluated an enhanced oxygen-sensing probe embedded with gold nanoparticles (GNP), called the OxyChip-GNP, to enable visualization of the sensor using routine clinical imaging modalities.

METHODS

In vitro characterization, imaging, and histopathology studies were carried out using tissue phantoms, excised tissues, and in vivo animal models (mice and rats).

RESULTS

The results demonstrated a substantial enhancement of ultrasound and CT contrast using the OxyChip-GNP without compromising its electron paramagnetic resonance and oxygen-sensing properties or biocompatibility.

CONCLUSIONS

The OxyChips embedded with gold nanoparticles (OxyChip-GNP) can be readily identified in soft tissues using standard clinical imaging modalities such as CT, cone beam-CT, or ultrasound imaging while maintaining its capability to make repeated in vivo measurements of tissue oxygen levels over the long term. This unique capability of the OxyChip-GNP facilitates precisely localized in vivo oxygen measurements in the clinical setting.

First-In-Human Study in Cancer Patients Establishing the Feasibility of Oxygen Measurements in Tumors Using Electron Paramagnetic Resonance With the OxyChip

OBJECTIVE

The overall objective of this clinical study was to validate an implantable oxygen sensor, called the 'OxyChip', as a clinically feasible technology that would allow individualized tumor-oxygen assessments in cancer patients prior to and during hypoxia-modification interventions such as hyperoxygen breathing.

METHODS

Patients with any solid tumor at ≤3-cm depth from the skin-surface scheduled to undergo surgical resection (with or without neoadjuvant therapy) were considered eligible for the study. The OxyChip was implanted in the tumor and subsequently removed during standard-of-care surgery. Partial pressure of oxygen (pO2) at the implant location was assessed using electron paramagnetic resonance (EPR) oximetry.

RESULTS

Twenty-three cancer patients underwent OxyChip implantation in their tumors. Six patients received neoadjuvant therapy while the OxyChip was implanted. Median implant duration was 30 days (range 4-128 days). Forty-five successful oxygen measurements were made in 15 patients. Baseline pO2 values were variable with overall median 15.7 mmHg (range 0.6-73.1 mmHg); 33% of the values were below 10 mmHg. After hyperoxygenation, the overall median pO2 was 31.8 mmHg (range 1.5-144.6 mmHg). In 83% of the measurements, there was a statistically significant (p ≤ 0.05) response to hyperoxygenation.

CONCLUSIONS

Measurement of baseline pO2 and response to hyperoxygenation using EPR oximetry with the OxyChip is clinically feasible in a variety of tumor types. Tumor oxygen at baseline differed significantly among patients. Although most tumors responded to a hyperoxygenation intervention, some were non-responders. These data demonstrated the need for individualized assessment of tumor oxygenation in the context of planned hyperoxygenation interventions to optimize clinical outcomes.

Evaluation of a Refined Implantable Resonator for Deep-Tissue EPR Oximetry in the Clinic

OBJECTIVES

(1) Summarize revisions made to the implantable resonator (IR) design and results of testing to characterize biocompatibility;(2) Demonstrate safety of implantation and feasibility of deep tissue oxygenation measurement using electron paramagnetic resonance (EPR) oximetry.

STUDY DESIGN

In vitro testing of the revised IR and in vivo implantation in rabbit brain and leg tissues.

METHODS

Revised IRs were fabricated with 1-4 OxyChips with a thin wire encapsulated with two biocompatible coatings. Biocompatibility and chemical characterization tests were performed. Rabbits were implanted with either an IR with 2 oxygen sensors or a biocompatible-control sample in both the brain and hind leg. The rabbits were implanted with IRs using a catheter-based, minimally invasive surgical procedure. EPR oximetry was performed for rabbits with IRs. Cohorts of rabbits were euthanized and tissues were obtained at 1 week, 3 months, and 9 months after implantation and examined for tissue reaction.

RESULTS

Biocompatibility and toxicity testing of the revised IRs demonstrated no abnormal reactions. EPR oximetry from brain and leg tissues were successfully executed. Blood work and histopathological evaluations showed no significant difference between the IR and control groups.

CONCLUSIONS

IRs were functional for up to 9 months after implantation and provided deep tissue oxygen measurements using EPR oximetry. Tissues surrounding the IRs showed no more tissue reaction than tissues surrounding the control samples. This pre-clinical study demonstrates that the IRs can be safely implanted in brain and leg tissues and that repeated, non-invasive, deep-tissue oxygen measurements can be obtained using in vivo EPR oximetry.

Estimation of pO2 distribution in EPR oximetry

Electron paramagnetic resonance (EPR) oximetry, using oxygen-sensing implant such as OxyChip, is capable of measuring oxygen concentration in vivo - a critical tissue information required for successful medical treatment such as cancer, wound healing and diabetes. Typically, EPR oximetry produces one value of the oxygen concentration, expressed as pO2 at the site of implant. However, it is well recognized that in vivo one deals with a distribution of oxygen concentration and therefore reporting just one number is not representative_a long-standing critique of EPR oximetry. Indeed, when it comes to the assessment of radiation efficacy one should be guided not by the mean or median but the proportion of oxygenated cancer cells which can be estimated only when the whole oxygen distribution in the tumor is known. Although there is a handful of papers attempting estimation of the oxygen distribution they suffer from the problem of negative frequencies and no theoretical justification and no biomedical interpretation. The goal of this work is to suggest a novel method using the empirical Bayesian approach realized via nonlinear mixed modeling with a priori distribution of oxygen following a two-parameter lognormal distribution with parameters estimated from the multi-implant single component EPR scan. Unlike previous work, the result of our estimation is the distribution with positive values for the frequency and the associated pO2 value. Our algorithm based on nonlinear regression is illustrated with EPR measurements on OxyChips equilibrated with gas mixtures containing four values of pO2 and computation of the proportion of volume with pO2 greater than any given threshold. This approach may become crucial for application of the EPR oximetry in clinical setting when the sucsess of the treatment depends of the proportion of tissue oxygenated.

Oxygen-Sensing Paramagnetic Probes for Clinical Oximetry

Electron paramagnetic resonance (EPR) oximetry based on lithium naphthalocyanine paramagnetic crystals as oxygen sensors enables direct measurement of the partial pressure of oxygen (pO₂) in tissues. The method uses topical or implantable forms of these oxygen-sensing crystals embedded in a biocompatible siloxane elastomer. This article presents a summary of these sensors for EPR oximetry and their applicability for tissue oxygen measurement in the clinic.

Transcutaneous oxygen measurement in humans using a paramagnetic skin adhesive film

PURPOSE

Transcutaneous oxygen tension (TcpO₂ ) provides information about blood perfusion in the tissue immediately below the skin. These data are valuable in assessing wound healing problems, diagnosing peripheral vascular/arterial insufficiency, and predicting disease progression or the response to therapy. Currently, TcpO₂ is primarily measured using electrochemical skin sensors, which consume oxygen and are prone to calibration errors. The goal of the present study was to develop a reliable method for TcpO₂ measurement in human subjects.

METHODS

We have developed a novel TcpO₂ oximetry method based on electron paramagnetic resonance (EPR) principles with an oxygen-sensing skin adhesive film, named the superficial perfusion oxygen tension (SPOT) chip. The SPOT chip is a 3-mm diameter, 60-μm thick circular film composed of a stable paramagnetic oxygen sensor. The chip is covered with an oxygen-barrier material on one side and secured on the skin by a medical adhesive transfer tape to ensure that only the oxygen that diffuses through the skin surface is measured. The method quantifies TcpO₂ through the linewidth of the EPR spectrum.

RESULTS

Repeated measurements using a cohort of 10 healthy human subjects showed that the TcpO₂ measurements were robust, reliable, and reproducible. The TcpO₂ values ranged from 7.8 ± 0.8 to 22.0 ± 1.0 mmHg in the volar forearm skin (N = 29) and 8.1 ± 0.3 to 23.4 ± 1.3 mmHg in the foot (N = 86).

CONCLUSIONS

The results demonstrated that the SPOT chip can measure TcpO₂ reliably and repeatedly under ambient conditions. The SPOT chip method could potentially be used to monitor TcpO₂ in the clinic.

Development of the Implantable Resonator System for Clinical EPR Oximetry

Hypoxic tumors are more resistant to radiotherapy and chemotherapy, which decreases the efficacy of these common forms of treatment. We have been developing implantable paramagnetic particulates to measure oxygen in vivo using electron paramagnetic resonance. Once implanted, oxygen can be measured repeatedly and non-invasively in superficial tissues (<3 cm deep), using an electron paramagnetic resonance spectrometer and an external surface-loop resonator. To significantly extend the clinical applications of electron paramagnetic resonance oximetry, we developed an implantable resonator system to obtain measurements at deeper sites. This system has been used to successfully obtain oxygen measurements in animal studies for several years. We report here on recent developments needed to meet the regulatory requirements to make this technology available for clinical use. radio frequency heating is discussed and magnetic resonance compatibility testing of the device has been carried out by a Good Laboratory Practice-certified laboratory. The geometry of the implantable resonator has been modified to meet our focused goal of verifying safety and efficacy for the proposed use of intracranial measurements and also for future use in tissue sites other than the brain. We have encapsulated the device within a smooth cylindrical-shaped silicone elastomer to prevent tissues from adhering to the device and to limit perturbation of tissue during implantation and removal. We have modified the configuration for simultaneously measuring oxygen at multiple sites by developing a linear array of oxygen sensing probes, which each provide independent measurements. If positive results are obtained in additional studies which evaluate biocompatibility and chemical characterization, we believe the implantable resonator will be at a suitable stage for initial testing in human subjects.

FLEXIBLE, WIRELESS, INDUCTIVELY COUPLED SURFACE COIL RESONATOR FOR EPR TOOTH DOSIMETRY

Managing radiation injuries following a catastrophic event where large numbers of people may have been exposed to life-threatening doses of ionizing radiation relies on the availability of biodosimetry to assess whether individuals need to be triaged for care. Electron Paramagnetic Resonance (EPR) tooth dosimetry is a viable method to accurately estimate the amount of ionizing radiation to which an individual has been exposed. In the intended measurement conditions and scenario, it is essential that the measurement process be fast, straightforward and provides meaningful and accurate dose estimations for individuals in the expected measurement conditions. The sensing component of a conventional L-band EPR spectrometer used for tooth dosimetry typically consists of a surface coil resonator that is rigidly, physically attached to the coupler. This design can result in cumbersome operation, limitations in teeth geometries that may be measured and hinder the overall utility of the dosimeter. A novel surface coil resonator has been developed for the currently existing L-band (1.15 GHz) EPR tooth dosimeter for the intended use as a point of care device by minimally trained operators. This resonator development provides further utility to the dosimeter, and increases the usability of the dosimeter by non-expert operators in the intended use scenario.

Dielectric-Backed Aperture Resonators for X-Band in vivo EPR Nail Dosimetry

A new resonator for X-band in vivo EPR nail dosimetry, the dielectric-backed aperture resonator (DAR), is developed based on rectangular TE₁₀₂ geometry. This novel geometry for surface spectroscopy improves at least a factor of 20 compared to a traditional non-backed aperture resonator. Such an increase in EPR sensitivity is achieved by using a non-resonant dielectric slab, placed on the aperture inside the cavity. The dielectric slab provides an increased magnetic field at the aperture and sample, while minimizing sensitive aperture resonance conditions. This work also introduces a DAR semi-spherical (SS)-TE₀₁₁ geometry. The SS-TE₀₁₁ geometry is attractive due to having twice the incident magnetic field at the aperture for a fixed input power. It has been shown that DAR provides sufficient sensitivity to make biologically relevant measurements both in vitro and in vivo Although in vivo tests have shown some effects of physiological motions that suggest the necessity of a more robust finger holder, equivalent dosimetry sensitivity of approximately 1.4 Gy has been demonstrated.

Surface Dielectric Resonators for X-band EPR Spectroscopy

A new resonator for X-band electron paramagnetic resonance (EPR) spectroscopy, which utilizes the unique resonance properties of dielectric substrates, has been developed using a single crystal of titanium dioxide. As a result of the dielectric properties of the crystal(s) chosen, this novel resonator provides the ability to make in vivo EPR spectroscopy surface measurements in the presence of lossy tissues at X-band frequencies (up to 10 GHz). A double-loop coupling device is used to transmit and receive microwave power to/from the resonator. This coupler has been developed and optimized for coupling to the resonator in the presence of lossy tissues to further enable in vivo measurements, such as in vivo EPR spectroscopy of human fingernails or teeth to measure the dose of ionizing radiation that a given individual has been exposed to. An advantage of this resonator for surface measurements is that the magnetic fields generated by the resonator are inherently shallow, which is desirable for in vivo nail dosimetry.

Advances in in vivo EPR Tooth BIOdosimetry: Meeting the targets for initial triage following a large-scale radiation event

Several important recent advances in the development and evolution of in vivo Tooth Biodosimetry using Electron Paramagnetic Resonance (EPR) allow its performance to meet or exceed the U.S. targeted requirements for accuracy and ease of operation and throughput in a large-scale radiation event. Ergonomically based changes to the magnet, coupled with the development of rotation of the magnet and advanced software to automate collection of data, have made it easier and faster to make a measurement. From start to finish, measurements require a total elapsed time of 5 min, with data acquisition taking place in less than 3 min. At the same time, the accuracy of the data for triage of large populations has improved, as indicated using the metrics of sensitivity, specificity and area under the ROC curve. Applying these standards to the intended population, EPR in vivo Tooth Biodosimetry has approximately the same diagnostic accuracy as the purported 'gold standard' (dicentric chromosome assay). Other improvements include miniaturisation of the spectrometer, leading to the creation of a significantly lighter and more compact prototype that is suitable for transporting for Point of Care (POC) operation and that can be operated off a single standard power outlet. Additional advancements in the resonator, including use of a disposable sensing loop attached to the incisor tooth, have resulted in a biodosimetry method where measurements can be made quickly with a simple 5-step workflow and by people needing only a few minutes of training (which can be built into the instrument as a training video). In sum, recent advancements allow this prototype to meet or exceed the US Federal Government's recommended targets for POC biodosimetry in large-scale events.

Tooth Retrospective Dosimetry Using Electron Paramagnetic Resonance: Influence of Irradiated Dental Composites

In the aftermath of a major radiological accident, the medical management of overexposed individuals will rely on the determination of the dose of ionizing radiations absorbed by the victims. Because people in the general population do not possess conventional dosimeters, after the fact dose reconstruction methods are needed. Free radicals are induced by radiations in the tooth enamel of victims, in direct proportion to dose, and can be quantified using Electron Paramagnetic Resonance (EPR) spectrometry, a technique that was demonstrated to be very appropriate for mass triage. The presence of dimethacrylate based restorations on teeth can interfere with the dosimetric signal from the enamel, as free radicals could also be induced in the various composites used. The aim of the present study was to screen irradiated composites for a possible radiation-induced EPR signal, to characterize it, and evaluate a possible interference with the dosimetric signal of the enamel. We investigated the most common commercial composites, and experimental compositions, for a possible class effect. The effect of the dose was studied between 10 Gy and 100 Gy using high sensitivity X-band spectrometer. The influence of this radiation-induced signal from the composite on the dosimetric signal of the enamel was also investigated using a clinical L-Band EPR spectrometer, specifically developed in the EPR center at Dartmouth College. In X-band, a radiation-induced signal was observed for high doses (25-100 Gy); it was rapidly decaying, and not detected after only 24h post irradiation. At 10 Gy, the signal was in most cases not measurable in the commercial composites tested, with the exception of 3 composites showing a significant intensity. In L-band study, only one irradiated commercial composite influenced significantly the dosimetric signal of the tooth, with an overestimation about 30%. In conclusion, the presence of the radiation-induced signal from dental composites should not significantly influence the dosimetry for early dose assessment.

Imaging tooth enamel using zero echo time (ZTE) magnetic resonance imaging

In an event where many thousands of people may have been exposed to levels of radiation that are sufficient to cause the acute radiation syndrome, we need technology that can estimate the absorbed dose on an individual basis for triage and meaningful medical decision making. Such dose estimates may be achieved using in vivo electron paramagnetic resonance (EPR) tooth biodosimetry, which measures the number of persistent free radicals that are generated in tooth enamel following irradiation. However, the accuracy of dose estimates may be impacted by individual variations in teeth, especially the amount and distribution of enamel in the inhomogeneous sensitive volume of the resonator used to detect the radicals. In order to study the relationship between interpersonal variations in enamel and EPR-based dose estimates, it is desirable to estimate these parameters nondestructively and without adding radiation to the teeth. Magnetic Resonance Imaging (MRI) is capable of acquiring structural and biochemical information without imparting additional radiation, which may be beneficial for many EPR dosimetry studies. However, the extremely short T2 relaxation time in tooth structures precludes tooth imaging using conventional MRI methods. Therefore, we used zero echo time (ZTE) MRI to image teeth ex vivo to assess enamel volumes and spatial distributions. Using these data in combination with the data on the distribution of the transverse radio frequency magnetic field from electromagnetic simulations, we then can identify possible sources of variations in radiation-induced signals detectable by EPR. Unlike conventional MRI, ZTE applies spatial encoding gradients during the RF excitation pulse, thereby facilitating signal acquisition almost immediately after excitation, minimizing signal loss from short T2 relaxation times. ZTE successfully provided volumetric measures of tooth enamel that may be related to variations that impact EPR dosimetry and facilitate the development of analytical procedures for individual dose estimates.

Electron paramagnetic resonance dosimetry for a large-scale radiation incident

With possibilities for radiation terrorism and intensified concerns about nuclear accidents since the recent Fukushima Daiichi event, the potential exposure of large numbers of individuals to radiation that could lead to acute clinical effects has become a major concern. For the medical community to cope with such an event and avoid overwhelming the medical care system, it is essential to identify not only individuals who have received clinically significant exposures and need medical intervention but also those who do not need treatment. The ability of electron paramagnetic resonance to measure radiation-induced paramagnetic species, which persist in certain tissues (e.g., teeth, fingernails, toenails, bone, and hair), has led to this technique becoming a prominent method for screening significantly exposed individuals. Although the technical requirements needed to develop this method for effective application in a radiation event are daunting, remarkable progress has been made. In collaboration with General Electric and through funding committed by the Biomedical Advanced Research and Development Authority, electron paramagnetic resonance tooth dosimetry of the upper incisors is being developed to become a Food and Drug Administration-approved and manufacturable device designed to carry out triage for a threshold dose of 2 Gy. Significant progress has also been made in the development of electron paramagnetic resonance nail dosimetry based on measurements of nails in situ under point-of-care conditions, and in the near future this may become a second field-ready technique. Based on recent progress in measurements of nail clippings, it is anticipated that this technique may be implementable at remotely located laboratories to provide additional information when the measurements of dose on-site need to be supplemented. The authors conclude that electron paramagnetic resonance dosimetry is likely to be a useful part of triage for a large-scale radiation incident.

The view from the trenches: part 2-technical considerations for EPR screening

There is growing awareness of the need for methodologies that can be used retrospectively to provide the biodosimetry needed to carry out screening and triage immediately after an event in which large numbers of people have potentially received clinically significant doses of ionizing radiation. The general approach to developing such methodologies has been a technology centric one, often ignoring the system integrations considerations that are key to their effective use. In this study an integrative approach for the evaluation and development of a physical biodosimetry technology was applied based on in vivo electron paramagnetic resonance (EPR) dosimetry. The EPR measurements are based on physical changes in tissues whose magnitudes are not affected by the factors that can confound biologically-based assessments. In this study the use of a pilot simulation exercise to evaluate an experimental EPR system and gather stakeholders' feedback early on in the development process is described. The exercise involved: ten non-irradiated participants, representatives from a local fire department; Department of Homeland Security certified exercise evaluators, EPR experts, physicians; and a human factors engineer. Stakeholders were in agreement that the EPR technology in its current state of development could be deployed for the screening of mass casualties. Furthermore, stakeholders' recommendations will be prioritized and incorporated in future developments of the EPR technique. While the results of this exercise were aimed specifically at providing feedback for the development of EPR dosimetry for screening mass casualties, the methods and lessons learned are likely to be applicable to other biodosimetric methods.